Lodve Stangeland

Complications and Death After Surgical Treatment of Small Bowel Obstruction: A 35-Year Institutional Experience

OBJECTIVE To study factors influencing complications and death after operations for small bowel obstruction (SBO) using multifactorial statistical methods. SUMMARY BACKGROUND DATA Death after surgery for SBO is believed to be influenced by factors such as old age, comorbidities, bowel gangrene, and delay in treatment. No studies have been reported in which adverse factors related to death and complications have been systematically investigated with modern statistical methods. METHODS The authors studied retrospectively 877 patients who underwent 1,007 operations for SBO from 1961 to 1995. Patients with paralytic ileus, intussusception, and abdominal cancer were excluded. Odds ratios for death, complications, postoperative hospital stay, and strangulation were calculated by means of logistic regression analyses. RESULTS Death and complication rates decreased during the study period. Old age, comorbidity, nonviable strangulation, and a treatment delay of more than 24 hours were significantly associated with an increased death rate. The rate of nonviable strangulation increased markedly with patient age. Major factors increasing the complication rate were old age, comorbidity, a treatment delay of more than 24 hours, and the need for repeat surgery. CONCLUSION Death and complication rates after SBO decreased from 1961 to 1995. Major factors influencing the rates were age, comorbidity, nonviable strangulation, and treatment delay. Nonviable strangulation was more common in old patients.

A comprehensive analysis of phase I and phase II metabolism gene polymorphisms and risk of non-small cell lung cancer in smokers

Lung cancer is a leading cause of cancer mortality worldwide with smoking and occupational exposure to carcinogenic compounds as the major risk factors. Susceptibility to lung cancer is affected by existence of polymorphic genes controlling the levels of metabolic activation and detoxification of carcinogens. We have investigated 105 single nucleotide polymorphisms (SNPs) in 31 genes from the phase I and phase II metabolism genes and antioxidant defense genes for association with the risk of non-small cell lung cancer (NSCLC) in a Norwegian population-based study. Our results indicate that several SNPs in the phase I genes, CYP1B1, CYP2D6, CYP2E1 and CYP3A4, are associated with the risk of NSCLC. Moreover, significant associations with multiple SNPs in the phase II genes ALDH2, COMT, EPHX1, SOD2, NAT1, NAT2, GSTM3, GSTP1, GSTT2 and MPO were also found. We prioritized our findings by use of two different recently developed Bayesian statistical tools, employing conservative prior probabilities of association. When we corrected for multiple testing using these statistical tools, three novel associations of NSCLC risk with SNPs in the CYP1B1 (Arg48Gly), COMT (Val158Met) and GSTT2 (Met139Ile) genes were found noteworthy. However, only four of the previously reported associations with polymorphisms in the GSTP1 (Ala14Val), SOD2 (Val16Ala), EPHX1 (His139Arg) genes and the NAT1 fast acetylator phenotype remained significantly associated with lung cancer.

Sex differences in risk of lung cancer: Expression of genes in the PAH bioactivation pathway in relation to smoking and bulky DNA adducts

It is controversial whether women have a higher lung cancer susceptibility compared to men. We previously reported higher levels of smoking‐related bulky DNA adducts in female lungs. In a pilot study (27 cases), we also found a higher level of female lung cytochrome P4501A1 (CYP1A1) gene expression. In the present extended study we report on the pulmonary expression of several genes involved in polycyclic aromatic hydrocarbon bioactivation in relation to sex, smoking and DNA adducts. CYP1A1, CYP1B1, aryl hydrocarbon receptor and microsomal epoxide hydrolase gene expression was measured by quantitative real‐time reverse transcriptase‐PCR in 121 normal lung tissue samples. The expression of CYP1A1 and CYP1B1 was significantly higher among current smokers compared to ex‐smokers and never‐smokers. Among current smokers, females had a 3.9‐fold higher median level of CYP1A1 compared to males (p = 0.011). CYP1B1 expression was not related to sex. Lung DNA adducts (measured by 32P‐postlabeling) were highly significantly related to CYP1A1 (p < 0.0001) irrespective of smoking‐status. Our results are consistent with the hypothesis that CYP1A1 plays a significant role in lung DNA adduct formation and support a higher susceptibility to lung cancer among females.

Perforated peptic ulcer over 56 years. Time trends in patients and disease characteristics.

Perforated gastroduodenal ulcer was studied in 1483 patients in the Bergen area during the years 1935-90 to discover time trends in age and sex, disease characteristics, treatment, and outcome. The male:female ratio fell from 10:1 to 1.5:1, median age increased from 41 to 62 years. Most perforations were found in the duodenum in 1935-64, and in the pyloric and praepyloric area in 1965-90. There was a 10% occurrence of gastric ulcers throughout the study period. Ulcer site was related to age (more gastric and less duodenal perforations with increasing age) and sex (more pyloric and less duodenal ulcers among women). There were twice as many perforations in the evening compared with the early morning. The diurnal variation was more pronounced for duodenal and pyloric than for gastric and praepyloric perforations. Circadian and seasonal variation of ulcer perforation did not change during the 56 years studied. Treatment delay increased from median five hours to median nine hours. Infective complications and mortality fell with the introduction of antibiotics around 1950. General complications has increased in recent years because of the increase of elderly patients. Among patients who died, the proportion with associated disease rose from 27 to 85% during the study period.

A specific interleukin-1B haplotype correlates with high levels of IL1B mRNA in the lung and increased risk of non-small cell lung cancer

Epidemiological evidence suggests a relationship between chronic inflammation and lung cancer. Inflammation in the lung may be modulated by host genetic factors such as polymorphisms in inflammatory genes. Identification of polymorphisms in inflammatory genes may help understanding interindividual differences in susceptibility to lung cancer. We have investigated single-nucleotide polymorphisms (SNPs) and their haplotypes in the regulatory region of the IL1B gene in association to non-small cell lung cancer (NSCLC) risk. Our previous work showed that two promoter SNPs C-511T and T-31C modulated NSCLC risk. In the present study, we show that G-3893A and G-1464C located in the enhancer region of the IL1B gene may also affect this risk, with odds for developing NSCLC being 0.69 [95% confidence interval (CI), 0.52-0.92] for -3893 A-allele and 0.63 (95% CI, 0.47 - 0.83) for -1464 C-allele. The associations were particularly prominent in patients with TP53 mutations in the tumor. Inference of the haplotype structures showed that -3893 G, -1464 G, -511 C and -31 T formed a specific haplotype (GGCT) with near complete linkage disequilibrium in lung cancer patients but not in controls. Furthermore, the risk haplotype (GGCT) was present in 65% of cases compared with 36% of controls. Quantitative analysis of RNA in normal lung tissue of the patients showed that the risk haplotype was correlated with significantly higher IL1B messenger RNA (mRNA) levels compared with the non-risk haplotype (ACTC). These data suggest that a specific IL1B haplotype associated with increased IL1B gene expression increases the risk of NSCLC.

Surgical treatment of spontaneous pneumothorax by wedge resection without pleurodesis or pleurectomy

OBJECTIVE Evaluation of wedge resection of the lung without pleurodesis or pleurectomy as a method of surgical treatment for spontaneous pneumothorax in terms of complications, recurrence rate and postoperative complaints. METHODS Retrospective study of 132 operations for spontaneous pneumothorax in 120 patients (84 men and 36 women: mean age 34 years, range 14-77) performed between 1974 and 1993. The mean observation time was 84 months (range 6-229) and a 100% follow-up rate of all survivors (97%) was achieved. RESULTS The indications for surgery were recurrent pneumothorax (52%), persisting air leak during first episode (45%), or hemothorax (3%). Perioperative findings were single bullous disease (86%), 2-3 bullae (6%), diffuse bullous disease (5%) and no bullous disease in 3% of the cases. The overall complication rate was 16% (30-day mortality 1%, reoperation for postoperative bleeding 2%, bronchopneumonia 8%, new pneumothorax during hospital stay 5%). The late recurrence rate (operated lung) was 5%. All recurrences were successfully treated by drainage (n = 3), exsufflation (n = 1) or observation only (n = 3). Reoperation was not necessary. Thirty-seven percent of the patients had postoperative complaints which they associated with the operation. CONCLUSION Lung resection without pleurodesis or pleurectomy is a simple, safe and effective method of the surgical treatment of spontaneous pneumothorax in terms of complications and recurrence rate in patients with limited bullous disease.

Patient survival and limb prognosis after arterial embolectomy

Mortality and morbidity after arterial thromboembolectomy were studied in 202 patients. Factors affecting reoperation and survival were identified according to Coxs proportional hazards model. 30-day mortality was 26% and amputation rate 18.5%. NYHA classification was the most important predictor for survival; class 3-4 had a 3.35 times higher death rate than class 1-2. An age greater than 75 years increased the death rate by 2.35 times and the presence of ischaemic heart or peripheral arteriosclerotic disease increased it by 1.69 and 1.65 times, respectively. Symptoms less than or equal to 1 day in duration were associated with a death rate 1.53 times higher than for a longer duration. Reoperation rate was 2.15 times greater in the absence of atrial dysrhythmias. The amputation rate was 3.79 times higher in NYHA class 3-4 than in class 1-2, and 2.47 times higher in the presence of peripheral arteriosclerotic disease. Apparently, thrombosis rather than recurrent embolism is the most important cause of reoperation and amputation. The severity of pre-existing cardiopulmonary disease largely determines prognosis regardless of the severity of the superimposed acute occlusion.

Dilation of the internal mammary artery by external and intraluminal papaverine application

Three methods for prevention of perioperative spasm of the internal mammary artery were compared in 78 patients undergoing coronary artery bypass grafting. In group 1, internal mammary artery pedicles were divided distally, clamped, and placed under the upper sternum submerged in papaverine solution (1.5 mg/ml). In group 2, as in group 1 but before clamping, 2 ml of heparinized blood with 1.5 mg/ml papaverine added was injected into the vessel lumen. In group 3 treatment was as in group 2, but heparinized blood with papaverine was injected a second time just before extracorporeal bypass was begun. In a univariate analysis free flow from dilated internal mammary arteries was not significantly different among the groups (group 1, 58 ml/min; group 2, 82 ml/min; group 3, 68 ml/min; p < 0.1). When free flow from dilated internal mammary arteries was the dependent variable in a regression analysis, the use of intraluminal papaverine, high blood pressure during flow measurement, and high initial blood flow were predictors of high flow (all p < 0.01). Morphometric measurements on the resected distal portion of the dilated internal mammary arteries disclosed less folding of the internal elastic lamina and a larger luminal area in groups 2 and 3 compared with respective findings in group 1 (1.21 mm2 and 1.42 mm2 versus 0.77 mm2; p < 0.02). Mechanical vessel wall injury occurred in 8 of 52 internal mammary arteries treated with intraluminal papaverine. Intraluminal papaverine solution injected once or twice in addition to external papaverine exposure therefore provides a better blood flow rate and distal dilation than mere submersion in papaverine solution, but at a considerable risk of mechanical wall injury.

Lipid accumulation in the myocardium during acute regional ischaemia in cats

Accumulation of lipid material in the myocardium was studied in cat hearts with acute regional ischaemia of 3 h duration. The fractional volume of lipid droplets in cytosol was analysed by electron microscopy of myocardial biopsies using a quantitative stereologic technique. Ischaemic and normally perfused myocardium were identified by fluoresceine injection, and tissue blood flow measurements were performed with labelled microspheres. In normal myocardium only small amounts of lipid droplets were found. A marked accumulation of lipid droplets occurred in borderline tissue between the two types of myocardium, whereas lipid accumulation in ischaemic myocardium was less pronounced. The arterial concentration of nonesterified fatty acids was clearly increased during the 3 h coronary artery occlusion period. Increased triglyceride synthesis from arterial fatty acids, or redistribution of intracellular lipids, are suggested as possible explanations for lipid accumulation during acute myocardial ischaemia.

Dynamic evaluation of fluid shifts during normothermic and hypothermic cardiopulmonary bypass in piglets

Background: Edema, generalized overhydration and organ dysfunction commonly occur in patients undergoing open‐heart surgery using cardiopulmonary bypass (CPB) and induced hypothermia. Activation of inflammatory reactions induced by contact between blood and foreign surfaces are commonly held responsible for the disturbances of fluid balance (“capillary leak syndrome”). We used an online technique to determine fluid shifts between the intravascular and the interstitial space during normothermic and hypothermic CPB.